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Wk 8, Case 5 - Review

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Patient History
62-year-old female with a history of aortic valve stenosis s/p bioprosthetic surgical aortic valve replacement, hypertension, mixed hyperlipidemia, and diabetes mellitus type 2 with symptoms of chest pain and shortness of breath with activity. Request for CCTA for further risk stratification.

Report
PROCEDURE:

1. Cardiac CT Angiography (Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed).) (CPT code: 75574)

TECHNIQUE:

Gating: Prospective; data acquisition between 70-75%

Medications: 200 mg Lopressor, 800 mcg sublingual nitroglycerin

Contrast: 85 mL Isovue 370 injected at 7mL/sec.

QC (signal/noise): Good

Artifacts: None

Complications: None

Heart rate: 50 bpm.

Findings:
CORONARY ANGIOGRAPHY:

The left and right coronaries arise from their respective normal anatomic ostia.

The coronary circulation is right dominant.

Left Main (LM):

The left main is a large caliber short vessel that bifurcates to form a left anterior descending, and a left circumflex artery. There is a small amount of non-calcified plaque with minimal (1-24%) stenosis in the distal left main.

Left anterior descending artery (LAD):

The LAD is a large caliber vessel that becomes a dual LAD that wraps the apex. There is a small amount of partially calcified plaque with minimal stenosis (1-24%) stenosis of the proximal LAD, and mid LAD. There is no plaque or stenosis in the distal LAD. The diagonal branches are patent.

Left circumflex artery (LCX):

The circumflex is a small caliber, non-dominant vessel that gives rise to two large branching obtuse marginal before terminating as a diminutive vessel within the AV groove. There is small amount of partially calcified plaque with a mild (25-49%) stenosis of the proximal LCX. There is no plaque or stenosis in the OM branches.

Right coronary artery (RCA):

The right coronary artery is a large caliber, dominant vessel, arising from the right cusp, that gives rise to acute marginal branches before terminating as the posterior descending artery and postero-lateral branches. There is a medium amount of non- calcified plaque with a mild (25-49%) stenosis of the proximal RCA, and minimal (1-24%) stenosis of the mid RCA. There is a medium amount of partially calcified plaque with positive remodeling and spotty calcification with a moderate (50-69%) stenosis of the distal RCA and a small amount of non-calcified plaque with positive remodeling and severe (70-99%) stenosis of the PLB.

NON-CORONARY CARDIAC FINDINGS:

Chambers: Left atrial size is dilated with no left atrial appendage filling defect. The left and right ventricular cavity size are within normal limits. There are no abnormal filling defects.

Myocardium: Severe increased wall thickness with severe anterior and posterior mitral annular calcification. No outpouching or masses.

Valves: Well seated bioprosthetic valve (21 mm Magna Ease). There is evidence of moderate (50-79%) hypoattenuating leaflet thickening (HALT) with calcification of the leaflets corresponding to the right and left coronary cusps. Moderate (50-79%) hypoattenuating leaflet thickening to the leaflet corresponding to the non-coronary cusp. There is a near circumferential irregular hypoattenuating thickening in the ventricular surface of the prosthetic valve ring consistent with pannus formation. Moderately thickened anterior mitral valve leaflet, and mildly thickened posterior mitral valve leaflet.

Pericardium: Normal thickness with no significant effusion or calcium present.

Aorta: Medium amount of partially calcified plaque in the visualized portions of the ascending and descending aorta. No aortic rupture, aneurysm, dissection, or intramural hematoma.

Pulmonary arteries: Normal in size without proximal filling defect. Not fully opacified.

Pulmonary veins: Normal pulmonary venous drainage. There are four pulmonary veins, two on the right and two on the left.

Impressions
1. Overall, there is a medium amount of partially calcified and non-calcified plaque with high-risk plaque features in a multivessel distribution.

2. Obstructive coronary artery disease with a 70-99% stenosis of the PLB, moderate 50-69%) stenosis of the distal RCA, mild (25-49%) stenosis of the proximal LCX, proximal RCA and minimal (1-24%) stenosis of the distal LM, proximal and mid LAD.

3. Moderate HALT involving all of the bioprosthetic valve leaflets with evidence of pannus formation in the prosthetic valve ring. Recommend further evaluation with echocardiography to assess for additional findings of bioprosthetic valve dysfunction.

RECOMMENDATIONS:

CAD-RADS 4A (Severe stenosis 70-99%). Aggressive risk factor modification and preventive medical therapy. Anti-anginal therapy recommended. Consider ICA and revascularization.

Modifier: High risk plaque features

Plaque: P2- Moderate amount of plaque

Final diagnosis: I25.10 CAD, native

Case Discussion

Faculty

Giovanni E. Lorenz, DO

Cardiothoracic Radiologist

San Antonio Military Health System (SAMHS)

Emilio Fentanes, MD

Director of Cardiac Imaging, Department of Cardiology

Brooke Army Medical Center

Tags

Vascular

Coronary arteries

Cardiac valves

Cardiac CT (SCCT Cat B1 Video Case)

Cardiac CT

Cardiac

Acquired/Developmental

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